Inflamed tonsils - operate or wait and see?
Tim snores. It's no longer the sweet snoring of a toddler - the six-year-old snores so loudly that his parents can hear him in the next room. He also doesn't recover properly at night and is constantly tired at school. His mum notices that he only breathes through his mouth and sometimes can't hear properly.
She takes Tim to the paediatrician. After a look in his mouth, everything is clear: his tonsils are huge - too big for him to breathe silently in his sleep. The enlarged tonsils are already covering the passage to the ear.
Restraint during operations due to infections
The paediatrician refers Tim to an ear, nose and throat specialist. «It's high time,» he says, « pauses in breathing at night can delay a child's development.» He disproves the mother's fear that Tim will stop breathing because of his snoring.
«Nowadays, obstruction of the upper airway is the main indication for a tonsillectomy,» says
indication for tonsillectomy," says ENT specialist Claudine Gysin from the University Children's Hospital Zurich. At the beginning of the 20th century, things were different: at that time, tonsils were removed almost exclusively due to infections, and so frequently that half of all operations on children were tonsillectomies, as the technical term goes.
This changed when antibiotics became available in the 1950s: «Recurrent tonsillitis is still an indication for surgery today, but a well-considered one,» says Claudine Gysin.
According to professional guidelines, tonsils are only removed when children fall ill with documented streptococcal angina five times a year for two years or more than three times a year for three years. According to Claudine Gysin, other recommendations apply to patients with additional systemic diseases.
There are no problems due to the absence of tonsils. «It is scientifically proven that children without tonsils do not have frequent respiratory infections,» confirms Vladeta Radivojevic, who runs an ENT practice in Zurich.
Tonsils are part of the body's defence system
The tonsils are part of the immune system that fights pathogens. There are the paired pharyngeal tonsils and the palatine and lingual tonsils, of which there is only one each. With their sponge-like tissue, in which bacteria and viruses remain trapped, they form a kind of protective barrier, as the mouth and nose are constantly in contact with the outside world.
In childhood, the tonsils produce antibodies and help to build up the immune system until the age of 12. «Many children have enlarged tonsils,» says Claudine Gysin. «The peak for the tonsils is in the 4th to 5th year of life, for the palatine tonsils in the 6th to 7th year.» However, the tonsils themselves can also become a problem if they are constantly inflamed. «Children who repeatedly suffer from angina should be referred to a specialist,» says Vladeta Radivojevic.
With the right indication, children could benefit from tonsillectomy: «There are children who are ill because of their tonsils. Once they are out, they get well again.»
Benefits and risks of tonsillectomy
Before an operation is even considered, various examinations are required, such as an endoscopic examination of the nasopharynx, hearing tests or pressure measurements. «We always take a comprehensive medical history,» says Radivojevic.
In children with a lot of tonsillitis, a complete documentation of the infections is necessary, and in those with enlarged tonsils, a sleep examination is sometimes also necessary. Both doctors emphasise that an operation must be carefully considered.
Tonsillectomy is very painful. Severe secondary haemorrhaging can also occur. This risk exists during the first 10 to 14 days. «Palatine and pharyngeal tonsils are often operated on together; pharyngeal tonsils can also be removed on their own,» says Radivojevic.
Instead of years of antibiotics - surgery
A tonsillectomy is performed as an inpatient under general anaesthetic. Most children are hospitalised for the first time during the procedure. Due to the risk of bleeding, there is no solid food in the post-operative period, and sport is also prohibited. The children are given porridge, yoghurt and lots of ice cream.
Despite the current reluctance, tonsillectomy makes sense if there is a clear indication. «Children in particular who have sleep apnoea because their tonsils are too large really blossom after an operation,» says Radivojevic. He also favours clarification in the case of repeated angina: «Instead of treating a child with antibiotics for years, it is worth clarifying whether an operation could be beneficial.»
Claudine Gysin recommends that the indication should always be well supported: «At Zurich Children's Hospital, 150 to 200 tonsillectomies are performed every year, most of them on very young children, but also on infants or children suffering from other illnesses.»
Gysin emphasises the important role of parents - not only for the procedure, but also for the decision-making process. This is not always easy: «On the one hand, we have the operation, which has its benefits but also its risks if it is well indicated; on the other hand, in many cases we also have room for manoeuvre to wait and see what develops.» A good dialogue with the parents is needed for this weighing up and decision-making.
Symptoms of enlarged tonsils
Enlarged adenoids obstruct nasal breathing. Children then always breathe through their mouths and also snore. If the palatine tonsils are enlarged, the children snore heavily, which can lead to respiratory distress syndrome - so-called sleep apnoea syndrome. In most cases, both the pharyngeal and palatine tonsils are enlarged.
Symptoms of chronically inflamed tonsils
This mainly affects the palatine tonsils. If these are inflamed, children have a sore throat, difficulty swallowing and fever. Constantly recurring infections can lead to purulent inflammation of the middle ear, hearing problems and, in rare cases, defects in the eardrum.
Indication for a tonsillectomy
- Enlarged pharyngeal or palatine tonsils that narrow the upper airways
- Recurrent inflammation of the tonsils
- systemic diseases
Three types of tonsils in the mouth, nose and throat
The palatine tonsils lie in pairs between the anterior and posterior palatine arches. The almond-shaped tissue belongs to the lymphatic pharyngeal ring, as does the pharyngeal tonsil, which lies on the roof of the pharynx. There are also the lingual tonsils, which, as the name suggests, are located on the surface of the posterior third of the tongue.
